"Bottom Line: What have you learned?" My boss is always challenging our Residents with this line. Educationally, we know that having to sum up the "take-home" message after an experience really cements it in the student's mind. So for this last blog, I'm going to try to draw from some observations and make some conclusions.
As I said back in January, my purpose has not been to compare New Zealand to the U.S., or even to compare medical systems. Although some comparison is inevitable I have tried to avoid thinking in this fashion. And I am under no illusions that I am here to change either place, or that I have the power to make much of a change. The question here is really, how have I changed from this experience.
I have been back home for 2 weeks now, and I have been welcomed back like a long-lost son. My first day back in clinic I got hugs from half my patients. Everyone seems happy to see me, and tells me "I bet you're glad to be back, aren't you?". And that's really felt good. Yes, I'm glad to be back, although I also miss New Zealand a lot. One thing I learned is that I'm not very attached to Cedar Rapids, despite living here for 12 years. We have some friends here, and my mother-in-law lives here when she's not gallivanting around the country. But I don't really have an attachment to this place like a lot of my patients and friends do. I didn't grow up here, there are no childhood memories, no exended family. Like a lot of Americans, I don't really have any roots in one particular locale. The place that I live is not a part of my identity- I can separate myself from that. I find it amazing that I could uproot my life and family so easily, and fit so comfortably in another place and culture so far away so easily. I feel a great sense of freedom about that.
Part of that is a boost in self-assurance from just being able to fall into a foreign practice and care for patients. I know I was feeling a bit out of touch, as an academic, with the day-to-day realities of practice. Having not been "in the trenches" for 12 years, it felt good to just be a doctor, see over 100 patients a week and experience that key exciting and terrifying challenge of being a generalist physician: i.e. never knowing what's going to walk through the door next. I like that challenge, I like relating to the patients and trying to understand their lives, and how life is for them. And it's helped me reaffirm that I am teaching my residents truely valuable skills. "Yes, computer skills will be critical in practice, but the trick is work the computer into a good bedside manner, to help BOND with the patient." "Yes, knowing how to look things up is essential, you need to do it with half of each day's cases." "Yes, prevention is really important, and building systems in office practice to facilitate prevention is the only way we'll ever get it done in medicine." "Yes, tracking your own data on your practice is useful to improving your quality of care." These were all things that I reaffirmed from my experience. And their being relevant in New Zealand, as well as in America., tells me that these beliefs are more universal than they are local or cultural.
I learned that I am a lucky man, as it doesn't take much to make me happy. We lived in a small house in New Zealand, with a wood/coal stove and "only" 1 car. It was not a hardship at all. I learned that daily exercise makes me feel better. I ate well, and lived a lower stress life, with amazing effects on my blood pressure. I have resolved to try to not be so driven or stressed, and to continue to take better care of myself, including getting adequate sleep and rest. I reconnected with my love of the natural world, and learned an entire new biology. Our walks in the woods and mountains, our nights under the stars, walks on the "ordinary" beaches of New Zealand put my place in the universe in perspective. I am only very small, and here for a very short time. And there is only this moment.
And I reconnected with the core reasons I became a physician in the first place. I remembered how I was originally admitted to medical school with a research background and an essay that could have been titled, "Why I want to be a research physician". After taking care of a struggling, low-income, new family in my First Year, I was seduced to join Family Practice. I liked patients a lot more than labwork. And it is the opportunity to sit and talk with people about their lives, and incidentally, their health, that to me is the core reason for becoming a doctor. I was lucky to have the opportunity to be a small-town G.P. in New Zealand. You can't be more of a physician than that.
This means I see with new eyes the effects of unbridled capitalism and consumerism on medical practice here at home. On returning to the U.S., some of the first concerns I heard were about the effects of malpractice on our health system. One of our local OB/Gyns has quit delivering because she can't get insurance, and our governor recently vetoed a package of malpractice reform. At the same time, an entire hospital system in the state has terminated its contract with an insurance administrator for the Medicaid program. This means that many low-income patients can no longer see their physicians or use their hospitals. An OB patient due to be delivered by Cesarian last week had just moved to Burlington, and had to come all the way back to Cedar Rapids (over 100 miles) to deliver because no one would see her in her home town. Our non-system is paradoxical. We have the best and most high tech medicine at some centers, and can truly perform miracles, but basic healthcare is lacking for over 10% of our population. We spend the most of any industrialized nation, and have the most unsatisfied patients. Part of that is high expectations that can't always be delivered (hence the number of lawsuits), but another part of the dissatisfaction is in being rushed and pushed though a system that too often treats the patient as a "head sheet" to be processed. And the financial pressures on this non-system will accelerate in the next 10-20 years. I've had a chance to think long and hard about what is ahead as I prepared my annual "Futurology" talk to the residents this week. I am sure we can do better than this in the U.S.
So what does all this mean. I'm not sure yet. Its too soon still to tell. Maybe I will move back to New Zealand in a few years. Maybe I will be more aggressive about challenging the assumptions of our current healthcare system. Maybe I can keep my blood pressure down by walking more. Only time will tell.
I have new stories to tell my residents, and new memories to make sense of. I've exceeded my objectives for this sabbatical beyond my wildest expectations. All I can say is that I can tell that I've changed from the experiences. And that was the whole point.
